Goal orientated progression of treatment is most likely one of the most important issues in rehabilitation in general as well as in musculoskeletal management. Several models and modalities of treatment progression have been proposed in literature touching different realms of rehabilitation. Elite sports specific rehabilitation uses, for example, strength and conditioning elements but reconditioning elements and global as well as specific functional strengthening is found to be very interesting to use also with normal patients for many different reasons.

Progression of treatment has been traditionally and historically covered in the Maitland concept, either in the Maitland books and more recently through internet and covers mainly the progression of treatment using manual therapy. The classic Manual Therapy progression scheme used in the Maitland concept is as follows:- Position of treatment

-Dosage of treatment (grade, rhythm, speed)

Technique

Direction, localization

Mobilizations, physiological or accessory

Manipulation

Home program

Ergonomic program

As clearly stated in Banks’ and Hengeveld’s Maitland peripheral manipulation, 2013, 8th edition “passive movement is not a panacea for all musculoskeletal disorders and should be considered in conjunction with other forms of physiotherapy and vice versa”. Several of the Banks and Hengeveld 2013 book’s “visions” on the use of passive treatment modalities have been challenged in the meantime with regards to the “importance” of passive examination and the role of passive movement in rehabilitation. Bank’s and Hengeveld in their book do raise some important questions;

“Does the patient have a neuromusculoskeletal disorder”? (probably intended as a dominant peripheral nociceptive disorder?, whereas not all disorders have dominant peripheral nociceptive components!)

“is the disorder movement related”? (disorders related to movement do not always imply that the disorder is dominantly related to peripheral nociceptive disorders)

“is mobilization/manipulation indicated”? (also very difficult to answer this question since indications of passive mobilization/manipulations are under constant scrutiny and discussion and clear answers to this question are difficult to make)

“will mobilization/manipulation fulfil the aims and desired effects of treatment”? (desired treatment effects maybe in itself very restrictive since therapy outcomes do not automatically imply the effectiveness of applied treatment, probably it is better to speak about desired treatment goals and necessary objectives to be able to reach the desired goals)

All these questions, although highly relevant, are under continuous discussion, often personal judgement as well as classification and categorization dependent, with the possibility of creating reasoning flaws, and definitely not easy to answer since there is not always a clear Yes/No answer possible.

Patient’s idea’s and expectations of health care may lead to the patients desire and frequently to the deliverance of mainly passive based therapies and are often related to either prior experience, reward, somatic focus and desire for a “quick fix”. These cultural believes might influence the therapists choice of therapeutic application. Interestingly some models used in traditional health care educations weigh heavily on the peripheral nociceptive/structural side whereas there is a vast and robust body of evidence to consider psychosocial and more “central” related explanations of symptom and pain modulation like for example “conditioned pain modulation”.

The therapists education, “professional culture” and subsequent believes influences and will determine the “therapists reasoning” and in a certain sense “freedom of choice” in the use of therapeutic modalities. These cultural and professional preferences for the use of passive therapeutic modalities may lead to “Internal conflict” as far as rehabilitation principles are concerned; “Self efficacy”; (self actualization, internal reinforcement” and “internal locus of control”, “self observation”, “self reaction” and “compliance” as well as “self evaluation”), and “behavioral change”.

Without doubt physiotherapists encounter in their careers enormous amounts of varieties of patient characteristics, pathologies, injuries, personal needs, requests and so forth. To be able to respond therapeutically to the individual variability of needs and request of patients the therapist must have an enormous amount of available knowledge and resources and need to monitor a great variety of possible progressions of recovery. So let’s highlight some other possible progressions during treatment:

Spontaneous progression or remission; The natural history of recovery after injury/pathology or disease is in most cases helped if an active lifestyle or “adaptive behavior” is undertaken. One example of adaptive behavior is after physical trauma where several models exist to facilitate recovery like:

PRICE (Protect, Rest, Ice, Compression, Elevation)

MEAT (Movement Exercise, Analgesics, Treatment)

POLICE (Protect, Optimal Loading, Ice, Compress, Elevate) An as active approach as possible (MEAT or POLICE initiating around 48 hours after initial trauma) is in most cases mandatory for speeding up recovery with several positive responses (central as well as peripheral) like immune system responses, encouraged and better functionally organized collagen formation as well as positive psychological, emotional and positive motor output adaptations.

Another example is spontaneous regression of symptoms and signs of low back pain. Disc herniations, in most cases, have a spontaneous regression over time.

Closely related to the above is progression through “Regression to the mean”, “the get better anyway effect” or natural pathways of symptom behavior maybe confounded with therapeutic success.

“If a person receives treatment intended to make him better, and gets better, then no power of reasoning known to medical science can convince him that it may not have been the treatment that restored his health”

Regression to the mean is a widespread statistical phenomenon with potentially serious implications for health care. It can result in wrongly concluding that an effect is due to treatment when it is due to chance. Ignorance of the problem will lead to errors in decision making. This misleads clinicians and patients into thinking that treatment has been effective and is a call for caution in interpreting patient improvements as causal effects of our actions.

Progression of Active Treatment through, Strength and Conditioning, Habituation, Adaptation and Neuroplasticity. It will be very important to have gathered enough information about “where and how” (initial dosage, baseline parameters) to start with your patient. Information about age, general condition and health, activity levels (e.g. sports-related) in daily life as well as initial data gathering through active testing and monitoring of individual capacities facilitates initial dosage calculations in terms of repetitions and sets. Very important is monitoring of weekly/monthly/ tri-mester and further in time, if necessary, progression and specific final and individual goal setting. Obviously the way of testing, the complexity of testing is very much related to the type of patient you encounter, some of the monitoring of progression may need specialized equipment.

Hopefully it has become clear that progression of treatment within a rehabilitation treatment protocol requires many different resources from the therapist. The enormous variability of patients we may see in daily practice forces us to carefully select treatment parameters and progression of treatment. I tried to describe some of the parameters of progression with which I have to deal regularly and some less regularly in my clinical work. There is no claim for completeness! I do hope that this blog may trigger curiosity and awareness of the complexity of working in the health care industry and in special mode in neuro-musculuskeletal rehabilitation.